BH09 Rapid resolution of chronic spontaneous urticaria with ritlecitinib in a patient with alopecia universalis

Abstract We present the case of a 50-year-old woman with a 1-year history of chronic spontaneous urticaria (CSU) and associated angio-oedema. At presentation, her Urticaria Activity Score (UAS7) was 41, and her Dermatology Life Quality Index (DLQI) was 30. Her medical history included hypothyroidism, asthma and childhood alopecia areata. Initial management included high-dose fexofenadine, famotidine, montelukast and omalizumab. While these interventions resolved her angio-oedema, they failed to improve her urticarial rash. During this treatment course, the patient developed rapidly progressing alopecia universalis. Pulsed dexamethasone provided modest improvement in her urticaria symptoms but did not alter the progression of her alopecia. Subsequently, ritlecitinib, a Janus kinase (JAK) inhibitor, was initiated for her alopecia universalis. Remarkably, within 2 days of starting ritlecitinib, the patient experienced complete resolution of her CSU symptoms. Post-treatment assessments revealed UAS7 and DLQI scores of 0, signifying full symptom control. The patient has since remained symptom free, with no recurrence of urticaria or angio-oedema. CSU is a debilitating condition that can significantly impact quality of life, especially when refractory to standard therapies. While JAK inhibitors are not established as a standard treatment for CSU, limited case series have documented the use of tofacitinib in refractory cases. However, the use of ritlecitinib in this context has not been reported to date. The rapid and sustained symptom resolution observed in this patient suggests the potential of ritlecitinib as a novel therapeutic option for refractory CSU. Further investigation is warranted to evaluate its broader clinical applicability and efficacy in CSU management.